2020 CMS Priorities, Goals, and Quality Improvement Activities IPRO - - PowerPoint PPT Presentation

▶
2020 cms priorities goals and quality improvement
SMART_READER_LITE
LIVE PREVIEW

2020 CMS Priorities, Goals, and Quality Improvement Activities IPRO - - PowerPoint PPT Presentation

Jul 12, 2023 27 likes •816 views

2020 CMS Priorities, Goals, and Quality Improvement Activities IPRO ESRD Network of New England (Network 1) Network Council Meeting December 11, 2019 1 Meeting Reminders This WebEx will be recorded and slides made available on the

slide-1
SLIDE 1

2020 CMS Priorities, Goals, and Quality Improvement Activities

1

IPRO ESRD Network of New England (Network 1) Network Council Meeting December 11, 2019

slide-2
SLIDE 2

Meeting Reminders

  • This WebEx will be recorded and slides made available on the Network

Website

  • All phone lines have been muted to avoid background noise
  • Be present and engaged in the presentations
  • Be prepared for active participation in the WebEx chat board
  • p. 2
slide-3
SLIDE 3

Meeting Reminders

  • Be prepared for active participation in polling questions
  • p. 3
slide-4
SLIDE 4

Agenda Topics

  • Overview of IPRO ESRD Program: Network 1
  • National ESRD Initiatives
  • Emergency Preparedness and Management
  • Patient Experience of Care
  • Patient Engagement
  • Quality Improvement Activities (QIA)
  • Information Management
  • Closing Comments
  • p. 4
slide-5
SLIDE 5

5

Overview of IPRO ESRD Program: Network 1

Danielle Daley, MBA Executive Director

slide-6
SLIDE 6

6

ESRD Networks

slide-7
SLIDE 7

7

IPRO ESRD Program

132,394

ESRD Patients

1,948

Dialysis Facilities

51

Transplant Centers

Network 9

IN, KY, OH

Network 6

GA, NC, SC

Network 1

CT, MA, ME, NH, RI, VT Patients: 15,334 Facilities: 201 Transplant: 15

Network 2

NY Patients: 30,846 Facilities: 325 Transplant: 13

Network 9

OH, KY, IN Patients: 34,570 Facilities: 650 Transplant: 14

Network 6

NC, SC, GA Patients: 51,644 Facilities: 772 Transplant: 9

NW2 NW1

IPRO ESRD Network Program Network Service Areas

slide-8
SLIDE 8

Mission Statement

The Mission of the IPRO End Stage Renal Disease (ESRD) Network Program is to promote health care for all ESRD patients that is safe, effective, efficient, patient-centered, timely, and equitable.

  • p. 8
slide-9
SLIDE 9

9 9

State ESRD Patient Census # of Dialysis Facilities # of Transplant Facilities Connecticut 4,442 52 2 Maine 1,171 20 1 Massachusetts 7,074 84 9 New Hampshire 1,113 20 1 Rhode Island 1,168 17 1 Vermont 366 8 1 TOTAL 15,334 201 15

Data Source: CROWNWeb 12/2019

Network Demographics By State

slide-10
SLIDE 10

10 10

Ownership ESRD Patient Census # of Dialysis Facilities American Renal Associates 1,730 24 DaVita 5,035 52 Dialysis Clinic Inc. 753 9 Diversified Specialty Institutes (DSI) 227 3 Fresenius Medical Care 6,102 80 Independent 1,334 28 US Renal Care, Inc. 58 1 Veterans Administration 95 4 TOTAL 15,334 201

Data Source: CROWNWeb 12/2019

Facility Affiliation By Organization

slide-11
SLIDE 11

Network 1 Staff

Danielle R. Daley, MBA Executive Director Email: danielle.daley@ipro.us Direct: (203) 285-1212 Agata Roszkowski, LMSW Patient Services Director Email: agata.roszkowski@ipro.us Direct: (203) 285-1213 Sarah Keehner, RN, BSN, CNN Quality Improvement Director Email: sarah.keehner@ipro.us Direct: (203) 285-1214 Jaya Bhargava, PhD, CPHQ Regional Operations Director Email: jaya.bhargava@ipro.us Direct: (203) 285-1215 Cheryl Pettway

  • Sr. Program Support Coordinator

Email: cheryl.pettway@ipro.us Direct: (203) 285-1222 TBD Community Outreach Coordinator Email: TBD Direct: (203) 285-1223 Nadine Caruthers, LPN Quality Improvement Coordinator Email: nadine.caruthers@ipro.us Direct: (203) 285-1224 Krystle Gonzalez Customer Service Manager Email: krystle.gonzalez@ipro.us Direct: (203) 285-1225

  • p. 11
slide-12
SLIDE 12

CMS Expectations Role of the Network

  • Improve quality of care for

ESRD patients

  • Provide assistance to ESRD patients

and providers

  • Encourage patient engagement
  • Evaluate and resolve patient

grievances

  • Collect data to measure quality
  • f care
  • Support emergency preparedness

and disaster response

  • p. 12
slide-13
SLIDE 13

Technical Assistance We’re Here to Help

  • The Network has tools to help with quality improvement activities

–Infection prevention –Catheter reduction –Transplant referrals

  • The Network provides technical assistance

–Data reporting –Patient engagement –Access to care barriers

  • p. 13

–Benefits of home dialysis –Peer mentoring –Vocational rehabilitation –Quality Incentive Program (QIP) –Patient/provider conflict –Patient safety

slide-14
SLIDE 14
  • The Network sponsors educational opportunities

–Face-to-Face Meetings –Webinars –Conference Calls

  • The Network shares data

–Comparative Network, state, and facility level –Incidence, prevalent, and demographic statistics –Annual Report

  • p. 14

Technical Assistance We’re Here to Help

slide-15
SLIDE 15

Are You Ready? We’re More Than Just a Number Let’s Test Your Memory Do You Know Your Network?

Polling Question

slide-16
SLIDE 16

16

Emergency Preparedness and Management

Agata Roszkowski, LMSW Patient Services Director Emergency Management Coordinator

slide-17
SLIDE 17

Emergency Management Things to Know

Facility Reporting/Tracking

  • Report Facility Status (Open/Closed/Altered)
  • Report patient access to care
  • Contact the Network to assist with local OEM

coordination efforts

Prepare Patients for an Emergency

  • Be prepared patient worksheet
  • 3-Day Emergency Diet

Prepare Your Facility for an Emergency

  • Technical assistance to facilities to develop

feasible, comprehensive emergency/disaster plans

  • p. 17
slide-18
SLIDE 18

Emergency Preparedness Overview

The Network 1 Emergency Preparedness and Management Plan

  • Roles during an emergency
  • Mobilization and response of the Network
  • Providing and maintaining support
  • Quality management of the emergency
  • p. 18
slide-19
SLIDE 19

Are You Ready? Frequency Emergency Planning We Want to Hear From You

Polling Question

slide-20
SLIDE 20

20

Patient Experience

  • f Care

Agata Roszkowski, LMSW Patient Services Director

slide-21
SLIDE 21

Patient Experience of Care Grievances Definition and the Network’s Role

  • What is a grievance?
  • Network’s Role

–Facilitator –Expert Investigator –Educator –Quality Improvement Specialist –Advocate –Referral Source

  • p. 21
slide-22
SLIDE 22

Patient Experience of Care Grievance Management and Best Practices

  • Development/support robust grievance

process

  • Foster environment that encourages

patients, family members, care partners to voice their opinions

  • Encourage positive resolution focused
  • utcomes
  • Establish an anonymous grievance

process

  • Grievance Educational Materials

–Network Grievance Poster –Forum Grievance Toolkit

  • p. 22
slide-23
SLIDE 23

CMS Expectations: Network Responsibilities

  • The Network assists with patient grievances

–Evaluate and resolve grievances using a patient centered approach –Follow CMS guidelines, document all Network steps of grievance resolution, and adhere to timeframes –Perform quality of care reviews using an interdisciplinary approach (LMSW / RN) –When necessary, refer cases to the Grievance Committee or Medical Review Board for review

  • p. 23
slide-24
SLIDE 24

CMS Expectations: Support for Access to Care Concerns

  • p. 24

Reasons for Access to Care Cases:

  • At-Risk of Involuntary Discharge
  • Involuntary Discharge
  • Involuntary Transfer
  • Failure to Place
  • Loss to Follow Up
slide-25
SLIDE 25

Patient Experience of Care Community Resources

  • Involuntary Discharge Resources

–Threats are Not Okay Here Poster –Involuntary Discharge Guide

  • Grievance Management Process Resources

–Dialysis Patient Grievance Toolkit

  • Communication Resources for staff and patients

–Applying Net Forward Energy in Patient Care Webinar –Relationship Centered Communication Webinar

  • p. 25
slide-26
SLIDE 26

Are You Ready? Management Disruptive Patient We Want to Hear From You

Polling Question

slide-27
SLIDE 27

27

Patient Engagement

Agata Roszkowski, LMSW Patient Services Director

slide-28
SLIDE 28

Patient Advisory Committee (PAC) Structure and Function

  • PAC members are :

–Promote communication between patients and staff –Inform patients about the ESRD Network –Reach patients in the New England area

  • PAC members are selected and nominated by facility staff
  • p. 28
slide-29
SLIDE 29

Patient Advisory Committee (PAC) Patient Facility Representative

  • Involved in the development of QIA interventions

and resources

  • Encouraged to participate in intervention

implementation at the facility

  • Patients are asked to:

–Consider becoming a Peer Mentor –Share their ESRD journey story with others –Attend meetings led by the Network –Participate in national meetings and technical expert panels

  • p. 29
slide-30
SLIDE 30

Patient Engagement Goals

  • Utilizing Peer to Peer model
  • Increase self management behaviors
  • Social support
  • Health related quality of life and self-efficiency
  • p. 30
slide-31
SLIDE 31

31

National ESRD Initiatives

Danielle Daley, MBA Executive Director

slide-32
SLIDE 32

ESRD Statement of Work December 2019 - November 2020

Background & Purpose

  • To delineate tasks to be conducted by each End Stage Renal

Disease (ESRD) Network Organization contractor in support of achieving national quality improvement goals and statutory requirements as set forth in Section 1881 of the Social Security Act and the Omnibus Budget Reconciliation Act of 1986

  • Tasks in this SOW are intended to align Network activities with:

– Department of Health and Human Services (HHS) National Quality Strategy (NQS) – HHS Secretary Priorities – Centers for Medicare & Medicaid Services (CMS) goals

  • p. 32
slide-33
SLIDE 33

ESRD Statement of Work December 2019 - November 2020

HHS Secretary’s Priorities 1. Opioid Crisis 2. Health Insurance Reform 3. Drug Pricing 4. Value-Based Care

  • p. 33
slide-34
SLIDE 34

ESRD Statement of Work December 2019 - November 2020

CMS Goals 1. Empower patients and doctors to make decisions about their health care 2. Usher in a new era of state flexibility and local leadership 3. Support innovative approaches to improve quality, accessibility, and affordability 4. Improve the CMS customer experience

  • p. 34
slide-35
SLIDE 35

ESRD Statement of Work December 2019 - November 2020

Areas of Focus

  • Aligned with Executive Order for Advancing American Kidney Health

(AAKH) –Reduce the number of Americans developing ESRD by 25% by 2030 –Doubling the number of kidneys available for transplant by 2030 –80% of new ESRD patients in 2025 either receiving dialysis at home or receiving a transplant

  • p. 35
slide-36
SLIDE 36

ESRD Statement of Work December 2019 - November 2020

Collaborations

  • National Coordinating Center (NCC)
  • Kidney Community Emergency Response Program (KCER)
  • State Survey Agencies
  • National Accreditation Agencies
  • Quality Innovation Networks (QIN-QIOs)
  • Hospital Improvement Innovation Network (HIIN)
  • Clinical Quality Improvement Contractors (CQICs)
  • p. 36
slide-37
SLIDE 37

37

Quality Improvement Initiatives

slide-38
SLIDE 38

ESRD Statement of Work Changes

Changes to Quality Improvement Activates

  • There are Network wide goals
  • No facility inclusion or exclusion criteria for any project
  • All facilities are expected to participate in each activity
  • p. 38
slide-39
SLIDE 39

ESRD Statement of Work December 2019 - November 2020

National Coordinating Center (NCC) Learning and Action Network (LAN) Events

  • Bi-monthly webinars, hosted on the first three Tuesdays of a month from

3:00- 4:00 pm starting January

  • Recordings of the event will be available on the NCC website 10 business

days after the event

  • CMS Certification Number (CCN) are required at registration to get credit

for attending

  • 1 free continuing education credit for nurses and technicians available for

each call

  • 18 total CEs available
  • p. 39
slide-40
SLIDE 40

ESRD Statement of Work December 2019 - November 2020

Learning & Action Networks (LANs)

  • Patient Experience of Care
  • Bloodstream Infections (BSI)
  • Home Dialysis
  • Patient and Family Engagement (PFE)
  • Transplant
  • Population Health Focused Pilot QIA (PHFPQ)
  • p. 40
slide-41
SLIDE 41

ESRD Statement of Work Monthly Communication

Monthly Data Collection Tool

  • Made available to facilities five business days prior to last day of

the month

  • Due to Network on the last working day of each month

Provide Insider

  • Monthly newsletter that will be disseminated on the first Tuesday of

each month

  • Contain links to education resources for QIAs, QIP, and webinar

registration

  • p. 41
slide-42
SLIDE 42

42

Making Care Safer by Reducing the Harm Caused in the Delivery of Care

Sarah Keehner, RN, BSN, CNN Quality Improvement Director

slide-43
SLIDE 43

Reducing Harm When Delivering Care Reduce Infections

Background

  • CMS has a goal to decrease the 2016 national infection rate 50%

by 2023

  • Contains 5 sub-projects:

–Bloodstream Infection Reduction –Long Term Catheter Reduction –Implementation of Center for Disease Control and Prevention Core Intervention –Completion of the National Healthcare and Safety Network Annual Event Surveillance Training –Improving process for communicating positive blood cultures between hospitals and dialysis facilities

  • p. 43
slide-44
SLIDE 44

Reducing Harm When Delivering Care Reduce Rates of Bloodstream Infections

Objectives

  • To reduce the number of positive blood cultures reported in NHSN by 20%

across New England Project Period

  • Baseline: January – June 2019
  • Re-measurement: January – June 2020

Requirements

  • Utilization of CDC Core Interventions
  • Conduct Root Cause Analysis (RCA)
  • NHSN Annual Dialysis Event Surveillance Training
  • p. 44
slide-45
SLIDE 45

Reducing Harm When Delivering Care Core Intervention for BSI Prevention

  • p. 45
slide-46
SLIDE 46

Are You Ready? Utilization CDC Core Interventions We Want to Hear From You

Polling Question

slide-47
SLIDE 47

Reducing Harm When Delivering Care Long Term Catheters Rate Reduction

Objective

  • To reduce the Network utilization rate of Long Term Catheters by 0.25%

Project Period

  • Baseline: July 2019
  • Re-measurement: CROWNWeb data available in October 2020

Requirements

  • Use peer to peer to share experience with catheter related infections
  • Improving the communication with vascular surgeons and interventional

radiologist

  • Improving surveillance of fistula and grafts
  • p. 47
slide-48
SLIDE 48

Reducing Harm When Delivering Care Enhancing Health Information Exchange

Objective

  • To enhance the process for communicating positive blood cultures

between hospitals and dialysis facilities Requirements

  • The Network shall obtain documentation from the facility that use of the

HIE platform or other evidence-based highly effective information transfer system is successful. This may include policy and procedure or less formal evidence of a system.

  • p. 48
slide-49
SLIDE 49

49

Promoting Modalities to Support AAKH

Nadine Caruthers, LPN Quality Improvement Coordinator

slide-50
SLIDE 50

Promote Appropriate Home Dialysis Increase Rates of Patients in Home

Objective

  • To increase the Network home dialysis rate by 2.5%

Project Period

  • Baseline: October 2019 CROWNWeb Data
  • Re-measurement: October 2020 CROWNWeb Data

Requirements

  • Encourage facilities to incorporate the seven steps leading to home dialysis

training into patient education, facility practice, and facility QAPI process

  • NCC Home Dialysis LAN participation
  • p. 50
slide-51
SLIDE 51

Promote Appropriate Home Dialysis Increase Rates of Patients in Home

Track and report to CMS the number of patients in each of the 7 steps each month: 1. Patient interest in home dialysis 2. Educational session to determine the patient’s preference of home modality 3. Patient suitability for home modality determined by a nephrologist with expertise in home dialysis therapy 4. Assessment for appropriate access placement 5. Placement of appropriate access 6. Patient accepted for home modality training 7. Patient begins home modality training

  • p. 51
slide-52
SLIDE 52

Promote Appropriate Home Dialysis Available Resources

  • p. 52
slide-53
SLIDE 53

Improve Transplant Coordination Increase Rates of Patients on Waitlist

Objective

  • Increase the number of patients on the kidney transplant waitlist by 1.25%

Project Period

  • Baseline is October 2019 UNOS Data
  • Re-measurement: October 2020 UNOS Data

Requirements

  • Monitor/track patient progress through five steps leading to placement on

transplant waitlist

  • p. 53
slide-54
SLIDE 54

Improve Transplant Coordination Increase Rates of Patients on Waitlist

Track and report to CMS the number of patients in each of the 5 steps each month: 1. Patient interest in transplant 2. Referral call to transplant center 3. First visit to transplant center 4. Transplant center work-up 5. On waiting list or evaluate potential living donor

  • p. 54
slide-55
SLIDE 55

Improve Transplant Coordination Available Resources

  • p. 55
slide-56
SLIDE 56

Are You Ready? For Patients Early Education We Want to Hear From You

Polling Question

slide-57
SLIDE 57

57

Quality Improvement Tools and Reporting

Sarah Keehner RN, BSN, CNN Quality Improvement Director

slide-58
SLIDE 58

Quality Improvement Tools Root Cause Analysis and Plan-Do-Study-Act

RCA

  • Conduct a RCA to identify the barriers for each initiative
  • Many ways to conduct an RCA
  • 5 Why’s
  • Fishbone
  • If a facility’s dialysis organization already utilizes a RCA tool then

that template many be used PDSA

  • Utilize the PDSA cycle to test the processes initiated to overcome

barriers

  • p. 58
slide-59
SLIDE 59

Quality Improvement Tools PDSA Template

  • p. 59
slide-60
SLIDE 60

Quality Improvement Tools Empathy Mapping

  • p. 60
slide-61
SLIDE 61

61

Data Management

Jaya Bhargava, PhD, CPHQ Regional Operations Director

slide-62
SLIDE 62

CMS Expectations: Facility Responsibilities ESRD Data Collection Systems

  • CMS Designated Data Collection Systems

–CROWNWeb

http://mycrownweb.org/assets/crownweb-dm/dm_guidelines/ –National Healthcare Safety Network (NHSN) https://www.cdc.gov/nhsn/dialysis/event/index.html

  • ESRD Outcome Reports

–Quality Incentive Program - https://cportal.qualitynet.org/QNet/pgm_select.jsp

  • Performance Score Reports and Certificates

–Dialysis Data - http://www.dialysisdata.org

  • Dialysis Facility Reports and Dialysis Facility Compare

–In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAPHS) - https://ichcahps.org/

  • Third Party Vendor
  • p. 62
slide-63
SLIDE 63

CMS Expectations: Network Responsibilities Data Reporting Assistance

  • Educate facilities to follow CMS Data

Management Guidelines

  • Inform providers of upcoming

deadlines

  • Streamlined process to inform

facilities of missing data

  • Working towards 100% patient level

data submission compliance – CROWNWeb – NHSN

  • p. 63

ESRD QIP NHSN

CROWNWeb

slide-64
SLIDE 64

CMS Expectations CROWNWeb Data Quality Goals

  • CMS issued

CROWNWeb Data Quality Goals

  • Established key

indicators and goals align with Data Management Guidelines

  • Used to assess facility

data submission and performance

  • p. 64
slide-65
SLIDE 65

CROWNWeb Data Reports from Network

  • Review reports and submit missing data in CROWNWeb
  • All data submissions are time sensitive but highest priority with immediate

action required are for:

–Missing Clinical Data reports - clinical month closes and cannot be changed –Facility Personnel Report – ensures the most current contact information is available for your facility

  • Your Facility Staff receive reports in these areas on a regular basis.

NEVER send PHI or PII via email to the Network

  • p. 65
slide-66
SLIDE 66

CROWNWeb Facility Personnel

  • p. 66
  • Monthly your CROWNWeb Data

contact receives report

  • Review and ensure Facility

Personnel in CROWNWeb is complete and accurate

slide-67
SLIDE 67

67 67

Technical Assistance Knowledge Base and Customer Portal

  • Platform for resolving and tracking requests for data assistance from

facilities in our region

  • Review articles related to different support topics
  • http://help.esrd.ipro.org/support/home
  • Submit a request for data assistance directly from the website or using

Email address below

  • NW1Help@iproesrdnetwork.freshdesk.com
  • Submit ticket for One-on-One Technical Assistance:
  • Use of WebEx “Meet Now” method for real-time assistance
  • p. 67
slide-68
SLIDE 68

REDCap

  • REDCap is a secure web application used for building and

managing online surveys

  • REDCap is provisioned by IPRO via Amazon Web Services (AWS)

GovCloud (HIPPA compliant)

  • It is used to collect virtually any type of data.
  • It can be used for surveys containing patient data.
  • Automatic reminders are set up
  • Act on the survey if a reminder is received.
  • p. 68
slide-69
SLIDE 69

Are You Ready? Fresdesk Customer Service Support Portal We Want to Hear From You

Polling Question

slide-70
SLIDE 70

70

Closing Comments

slide-71
SLIDE 71

CMS Expectations Facility Responsibilities

  • Participate in Network Quality Improvement Activities (QIAs)
  • Inform patients of available Network resources

–Grievance resolution –Educational materials –Peer-to-peer mentoring

  • Notify the Network of major events

–Facility emergencies –Leadership changes

  • Respond to inquiries and requests for information
  • p. 71
slide-72
SLIDE 72

CMS Expectations Facility Responsibilities

  • Timely submission of data
  • Keep facility personnel information updated in CROWNWeb
  • Discuss challenges/barriers

**Communicate with the Network**

  • p. 72
slide-73
SLIDE 73

ESRD Network of New England Website http://network1.esrd.ipro.org

  • p. 73
slide-74
SLIDE 74

IPRO ESRD Program Facebook Page https://www.facebook.com/IPROESRDProgram

  • p. 74
slide-75
SLIDE 75

ESRD Network of New England 2020 Educational Opportunity

Home Modalities Learning Series

  • Spring 2020
  • A Center Experience: The Impact of Transitional Start Unit
  • HHD: Adequacy, Prescriptions and Outcomes
  • Transitions in Care: A patient road map for transitioning prevalent from

In-Center to Home Kidney Discard and High Kidney Donor Profile Index (KDPI) Webinar

  • Spring 2020

8th Annual ESRD New England Fall Conference

  • October 8, 2020

– Mohegan Sun, Uncasville, Connecticut

  • p. 75
slide-76
SLIDE 76

Action Items During the Month of December

  • Conduct “Know Your Network” in-service with all dialysis facility staff
  • Identify at least one patient and/or family member or caregiver to participate

in facility and Network engagement activities

  • Review facility personnel in CROWNWeb and update individual records

accordingly

  • Educate dialysis staff about the facility’s CMS Certification Number (CCN)
  • Conduct Root Cause Analysis (RCA) to identify barriers to reaching

successful outcomes regarding the 2020 initiatives for improving kidney health

  • p. 76
slide-77
SLIDE 77
  • p. 77
slide-78
SLIDE 78

Presentation Template Draft for Review

April 6, 2017

  • p. 1

Corporate Headquarters 1979 Marcus Avenue Lake Success, NY 11042-1002 www.ipro.org

For more information:

Danielle Daley, MBA Jaya Bhargava, PhD, CPHQ Executive Director Regional Operations Director (203) 285-1212 (203) 285-1215 danielle.daley@ipro.us jaya.bhargava@ipro.us Sarah Keehner, RN, BSN, CNN Agata Roszkowski, LMSW Quality Improvement Director Patient Services Director (203) 285-1214 (203) 285-1213 sarah.keehner@ipro.ust agata.roskowski@ipro.us